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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. <br /> Date Issued-5 6_,."77 <br /> ---_-------------------------------- ------.-- - This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> .This application is made in compliance with County <br /> O]rddinanncee No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION --- --�0__ So-J..- -e Y ------- - -..---------CENSUS TRACT.......... _.. -... <br /> Owner's Name.___ _ <br /> r - -� -..Phone------ - <br /> - ..._ <br /> Address - -._... - <br /> >•. �- - -- -- - C111'................- ----------------- Zip-------------------- <br /> Contractor's Name.-_. 'a ------------ <br /> -�C� - ".-_ License #-,3_U_ff.7/_Phone-_0?_-,?/P__41.1. <br /> —Installation will serve: Residence [1,-,"Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-....-- ..- _ ------"......----------- <br /> Number of living units:___I-----_--Number of bedrooms_---"fes_Garbage Grinder.----------Lot Size__-_ -"_ <br /> `Water Supply: Public System and name - -------------- --------- ----- ------- "-------------- -------- - Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material____-___If yes, type___-_____---_----.------ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) r r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size_--.-_ -_ --..- - Li r y <br /> QQ 0 X- -X ---- quid Depth -----------------� <br /> Capacity.. =ot-d-JP__.Type_--.IF1-_--.._---.Material_ _ " -------- No. Compartments------ <br /> Distance to nearest: Well -------___/fJ_Q--.------------Foundation.---y=0-------------Prop. Line__IG.Q_-.__--_.D <br /> LEACHING LINE ( ] No. of Lines-__I--.--------._____.Length of each line.__--_"�Lo----__._..Total Length.---.f}-b--_--_.----_-_.__.---1n <br /> 'D' Box------..---.Type Filter Material-_-_ -.Depth Filter Material-----J-. -----------------------------_----------.--__-__.r <br /> �j Distance to nearest: _ --- . ---------.__Fd _ <br /> Foundation arestWellL- A?-----------------Property Line----.GQ------------ ------- <br /> SEE2,AGL-P1T [ ] Depth_91IP_MMeter--- ----------------Number______---_------------- Rock Filled Yes No <br /> Water Table Depth_.' ........------------------------------------------Rock Size-----{- ------------------------- <br /> Distance to nearest: Well----------)d"m.-.._-__----.-_ ----.Foundation-------------------------.Prop. Line-------------______-_ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date----------------------------------------------) <br /> —Septic Tank (Specify Requirements)---------------------- ----------------------------------------------------------------------------'--- -------------------------- --------------- <br /> Disposal Field (Specify Requirements)------------------ ----- ---------------------=----------- ----------------- -----' -- '- <br /> C <br /> ` -----------...--- <br /> ------- <br /> ----- <br /> ---- <br /> - ---------------------------- --- - --- '---- _--------------- ---------'----------------- - .. '-------------------------- ---- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> `Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> `to become subject to Workman's Compensation laws of California." <br /> I, Signed' ' - - - - ----- - Owner <br /> LBy - - - - - Title - - ...--_----- <br /> I oth an owner( <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY......_... . tL-,,Y- ' --- -7 <br /> --- - -------- -- ----- --- ---------- - ---DATE --- <br /> ------------- <br /> DIVISION --- <br /> OF LAND NUMBER - ------------ _ DATE..-- -- <br /> ---- _- ---------------------- <br /> ------------ <br /> ---------------------------------------------------------------------------- <br /> ADDITIONALCOMMENTS --------- -----------------'------------------------------------------------------------------------- - --------------------------...---- <br /> -------- - -------------------- -------- ----- --------------- - ------------------------------------------------- - -------- ------ ------------------------ --- --------------------------- ---- <br /> ---------------------------------__----------------- <br /> ---------------------------------__---------------- - ---- ----- ----------------------------------------------------------- ----------------------------------------'---------------- <br /> ------------- ---- - <br /> Final Inspection by:.-. ...:``/. -_wi. - -- - ----------------------------'--__------------------------------------Date ----- -------------------------- <br /> ` EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV.7/76 3M <br />